Latinos/Hispanics in the U.S. constitute a racially and culturally heterogeneous ethnic group that historically has temporarily stayed or permanently migrated for different reasons, including economic opportunity and/or political persecution [1]. Consequently, Latinos/ Hispanics have become the largest ethnic minority group in the U.S., comprising more than 15% of its population (U.S. Census Bureau) and as the fastest growing ethnic minority population projected to more than double between 2000 and 2050 [1,2].

Regarding health status, Latinos living in the U.S. have a higher incidence of chronic diseases, including diabetes, hypertension, heart disease, and obesity and have fewer physician visits in 12 months when compared to non-Hispanic Whites [3-5]. The Latino/Hispanic population appears to use health care services differently when compared to other ethnic groups. Although access health care is the most frequently mentioned barrier to good health for Latinos, it is not the only influential factor, nor is it the only determinant of good health. A national trend analysis found that among individuals 50 years and older, Latinos self-ranked their health as the worst, when compared with their non-Latino White and African American counterparts [1,2]. Latinos in the U.S. as a group have the lowest rate of health insurance coverage—29% uninsured as compared to a 10.4% for the White population group and also lower household income compared to non- Hispanic Whites households ($39,000 vs. $50,000) [6,7].

Although the Latino/Hispanic population is constantly increasing and its health concerns are being studied, there is little research about the Latino men health status and decision-making. Concerning Latino/Hispanic males in particular, adequate access to health education can be lifesaving and recent studies show that this group is more likely to die from diabetes, chronic liver disease, liver cancer [3,8] and human immunodeficiency virus/acquired immunodeficiency syndrome [1].

The concept of fatalism, as related to the reliance on fatalistic beliefs and lack of faith in preventive medicine have been studied in Latino/ Hispanic men as affecting the use of health education and screenings that target disease prevention [6]. Moreover, the status of Latino/Hispanic men’s health decision-making is potentially affected by cultural values such as machismo, which is defined as the cultural value that Latino / Hispanic men are expected to behave in a masculine way and masculine identity in which males are self-reliant, strong, robust, and should never reveal vulnerability [8,9]. There is the assumption that Latino immigrants that have lived for longer periods in the U.S., are members of a later immigrant generation, and are fluent Englishspeakers, represent higher levels of acculturation and lower levels of machismo [10]. However, even after becoming acculturated to an American way of life, machismo can affect how Latino men understand and respond to health decision making and health care access [2].

Contradicting with machismo is the concept of caballerismo also present in the literature as a significant factor for Latino/ Hispanic men decision making and healthcare use. Caballerismo is the prosocial view of masculinity and is centered on the idea that manhood can be rooted in family centeredness, social responsibility, and emotional connectedness [6]. For example, a recent study by Garcia, Valdez, and Hooker concluded that the Latino/Hispanic men perceived responsibility of the future of their families as an influential factor to better health decision making and use of healthcare services. The increased vulnerability that comes with disease and its potential complications, such as being unable to fulfill their traditional responsibilities serves as motivation to change behaviors [8]. Apparently, for Latino/Hispanic men it would be easier to follow a healthy diet regimen if the whole family is doing the same and Latina/Hispanic spouses have a large influence on diet and physical activity–related behaviors.

Culture is an important societal factor determining the values, beliefs, and behaviors of an individual or group [11]. Cultural competence is a complex know-act affecting the cognitive, emotional, behavioral, and environmental dimensions of a person; involving knowledge, skills, and that leads to a culturally effective action [12]. Cultural competence is necessary for providing quality care and is an ongoing process that involves accepting and respecting differences, while not letting personal beliefs have undue influence on those whose worldview is different [13].

The Latino/Hispanic community is potentially a complex group due to its significant variations in racial and ethnic heritages. Structural factors such as the lack of culturally and linguistically competent health programs and services have been identified as barriers to Latino/Hispanic health decision making and healthcare use [9]. Thus the importance of a culturally competent health education that increases the extent to which individuals are well informed about health care matters such as nutrition, sanitation, and the availability of health care resources [4] integrating cultural safety, considering the perception of the recipient and taking in consideration the outcome of cultural competence.

Methodology

Recruitment: Culturally competent flyers were used as advertising targeting Latino/Hispanic men and distributed in three Catholic churches located in the city of Atlanta, which have Spanish mass services and high Latino/Hispanic attendance. The advertising also targeted women to recruit their male spouses/partners.

Sample characteristics: Out of the 64 participants that volunteered, 50 participants were selected to attend he five-week long education training, based on the following criteria:

1. Male Latino/Hispanic

2. Age range 40-65

3. Resident of the city of Atlanta

4. Diabetes type II diagnosis by their primary physician for more than one year

5. Receiving diabetes prescription medication

6. Not engaging in any other specific health activity intended to support diabetes type II control (ex. Exercise, diet)

The study sample was composed of 50 Hispanic males, primarily of Mexican descent (62%), living in the city of Atlanta. The majority of the participants were in the 56-60 years old age range (30%) with a high school degree or below (88%) and not proficient in English (94%).

Moreover, the large majority of the participants (82%) had an annual household income of $25,000 or less. The demographic characteristics of the study participants are listed below in Table 1.

Table 1: Demographic characteristics of study participants.

Literature research: For this concept study, and for the preparation of the training sessions, nutrition literature, literature connected with medicine, and sociology was used as reference sources. Sample articles were derived from different online databases selecting the most appropriate for the purpose of this study.

Education training: Participants were asked to attend a Nutrition education training every week. The sessions took place Saturday mornings and lasted 1 to 2 hours, depending on the topic discussed. Participants were sent reminders via text message of the date and time of the upcoming session.

Latino /Hispanic health professionals with culturally competent skills presented the education-training sessions in Spanish. All handouts and presentation materials were translated to Spanish. All sessions included a formal presentation followed by an interactive activity. As family involvement is a crucial, the participants were allowed to bring their spouses and family members to the sessions as guest participants. Participants were allowed enough time to ask questions and engage in group discussions.

Participants were asked to implement the knowledge learned at home and to measure glucose levels daily. A tracking sheet was provided for participants to enter blood glucose levels after measurement. Participants were asked to bring the tracking sheet to each session, for staff to enter data into the statistical software.

Evaluation forms were provided for the participants to complete by the end of each session and participants were asked to rate the sessions 0-10 points based on the professionalism of the presenters, relevancy of the information presented and overall quality of the presentation.

A summary of the session topics, description, duration, attendees and rating of the five-week education training is provided below in Table 2.

Table 2: Five-week education training summary and participant rating.

Data obtained from the participants was entered weekly and analyzed using statistical software. Additional data was collected regarding three other health factors:

1. Height- measured upon entrance to the program

2. Weight- measured weekly

3. Body Mass Index (BMI) - calculated weekly as well.

BMI calculates the healthy weight based on height. The following criteria were used to analyze BMI results.

• Underweight: BMI is less than 18.5

• Normal weight: BMI is 18.5 to 24.9

• Overweight: BMI is 25 to 29.9

• Obese: BMI is 30 or more

Results of the study revealed a decline and stabilization in glucose levels for the participants with high glucose levels who reported to have taken the diabetes medication as prescribed by their primary physician and have implemented the knowledge learned. Weight loss was also noted for 38 participants who were intentionally interested in losing weight as a result of the program.

Participants highlighted the benefit of the presence of the family members as motivators for behavior change and the social support provided during the sessions. Participants commented that after hearing from people in similar situations, they were able to better relate and understand the information that was being presented and mentioned a preference for group sessions rather than individual consultations. Moreover, participants emphasized on the benefit of learning how to integrate healthy food choices to culturally bound dietary norms and to work with their family structure to promoted healthy behaviors. Participants also demonstrated interest in the integration of technologies such as phone apps, and other innovative approaches to assist with blood sugar control and healthy diet habits. Glucose, Weight and BMI results are provided below in Tables 3 and 4.

Table 3: Glucose results of study participants.

Table 4: Weight and BMI results of study participants.

In order to decrease health disparities in the Latino/Hispanic men population, sociocultural factors need to be addressed. A culturally competent system instructing professionals on how culture and gender influence the health behaviors of Latino/Hispanic men should be taken in consideration when planning and implementing health related programs in the community. As the results of this study conclude, culturally competent health and nutrition education trainings on diabetes type II control can make a significant impact in the health and nutritional status of male Latino/Hispanics.

This study had limitations that should be acknowledged. The study sample was composed of Hispanic males, primarily of Mexican descent, living in the city of Atlanta, which may limit the generalizability of the findings to Hispanics in other regions of the United States. Furthermore, the study sample was predominantly foreign-born, and Spanish-speaking. Lack of supplies, and forgetfulness, were reasons for some patients not measuring glucose levels and entering data. Missing glucose level data could have slightly altered the results of the study.